General Contact Information
Name
*
First Name
Last Name
Please list any names you have previously held.
Today's Date
*
Birthdate
*
Please select a month
January
February
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Month
Please select a day
1
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Day
Please select a year
2026
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1929
1928
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1925
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1923
1922
1921
1920
Year
Current Age
*
Gender
*
Male
Female
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select what time zone you are located in.
Please Select
Eastern Standard Time
Central Standard Time
Mountain Standard Time
Pacific Standard Time
Other
Name of Emergency Contact
*
First Name
Last Name
Relationship to Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred Here By?
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Education, Employment, & Religion
Highest Level of Education
Please list any other degrees, certificates, or trainings completed.
Employer (Current or Last)
*
What was your position at current or last employer?
*
Number of Years Employed Here
*
Past Occupations (Employers & Positions)
Does your present work satisfy you? If not, please explain.
What religion do you associate with?
Denomination/Sect preference, if any?
Church Presently Attending (N/A, if not applicable.)
How often do you attend church?
Are you a member?
*
Please Select
Yes
No
In Process
How long have you attended?
Please describe your current involvement at this church.
Pastor/Elder or Other Church Leaders Name
*
First Name
Last Name
Pastor/Elder or Other Church Leaders Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reigning Grace will be reaching out to your pastor/elder. We understand that there are rare situations in which contacting your pastor/elder would not be helpful. If this is one of those situations, please explain the situation and why you would prefer we not reach out below. Please put N/A if this does not apply.
*
Does your pastor know of your decision to seek biblical counseling?
Please Select
Yes
No
Have you been/are you under church discipline?
Please Select
No.
Yes, I have been.
Yes, I am currently.
If yes to the above question, what church?
Names of previous churches and reasons for leaving.
Have you been baptized?
Please Select
Never
As an infant
After getting saved
Other
If you were baptized after infancy, what was your age?
Describe your own understanding of God.
What is your level of confidence in God?
Do you pray to God?
Never
Occasionally
Not Sure
Always
Other
Are you forgiven by God? Would you go to heaven if you died?
Please Select
Yes
No
Not Sure
How frequently do you read the Bible?
Please Select
Never
Occasionally
Often
Do you read your Bible with your spouse and children?
Please Select
Never
Occasionally
Often
Do you have a relationship with Jesus Christ? If so, briefly explain how this came about.
What are God's expectations of you currently?
What is your greatest spiritual need at this point?
Have you participated in.. (Check all that apply).
Masonic Lodge
Scientology
Jehovah Witness
Mormonism
Out-of-Body Experiences/Trances
Meditation
Occult
Cult
Witchcraft/Wicca
Sorcery
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Health & Lifestyle
My health is...
*
Very Good
Good
Average
Less Than Average
Poor
I consider myself...
*
Heterosexual
Bisexual
Homosexual
Unsure
Have you ever had gender-reassignment surgery?
*
Yes
No
I'm considering it
Are you currently taking hormones or undergoing treatment to transition to another sex/gender?
*
Yes
No
I'm considering it
If yes, to either of the above questions, please explain. If no, write N/A.
*
Please list any current health issues.
Name & Facility of Primary Physician
Please list all current medications. Include prescriptions, over the counter, diet pills, laxatives, birth control pills, cold & allergy medicine, supplements, and pain relievers. List name and purpose of each.
Have you had any of the following problems?
Heart Problems
Liver Problems
Visual Problems
Sensory Distortion
Weakness
Problems Walking
Unusual Hair Loss
Parkinson's Disease
Blackouts
Amnesia
Constant Hunger
Headaches
Dizziness
Speech Problems
Lung Problems
Bulimia
Anorexia
Hallucinations
Change in Sex Drive
Seizures
Brain Tumor
Multiple Sclerosis
Nausea/Vomiting
Weight Change
Personality Change
Food Cravings
Allergies
Cancer
High Blood Pressure
Head Injury/Concussion
Kidney Problems
Stroke
Fatigue
Memory Problems
Tremors
Thyroid Disfunction
Diabetes
Hypoglycemia
Incoordination
Other
If you selected yes to any of the above, please explain.
What is your daily caffeine consumption?
Average Hours of Sleep per Night.
Do you have problems sleeping?
*
Yes
No
Average Sleep Quality.
*
Good
Fair
Poor
Recent Weight Changes
Gained
Lost
If applicable, please explain your weight change.
Please list any previous surgeries (those which required anesthesia).
*
(Women Only) Have you had any menstrual difficulties? Do you experience tension, tendency to cry, or other symptoms to your cycle? Please explain.
Is your husband in favor of you coming to counseling? If no, please explain.
Have you recently experienced a severe upset, nervous breakdown, or life-changing crisis?
Have you recently experienced a panic attack?
Did the crisis or panic attack require hospitalization?
Have you experienced hallucinations?
Yes
No
Do you experience the feeling that people are watching you?
Yes
No
Suicidal Thoughts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Suicidal Plans? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Suicidal Attempts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Have you had any close family/friend/coworker commit suicide? If yes, please explain the relation to you and when.
Homicidal Thoughts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Homicidal Plans? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Homicidal Attempts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Have you ever experienced physical abuse?
Have you ever experienced mental abuse?
Have you ever experienced emotional abuse?
Have you ever experienced rape or inappropriate touch?
Have you ever been involved in the abuse of another person?
Have you ever been involved in the molestation of another person?
In the past year, have you experienced the loss of someone who was close to you? If yes, please explain.
What was your age at your first exposure to pornography?
Use of Pornography
Daily
Weekly
Monthly
Rarely
None
What is your total number of sexual partners?
Have you had concerns about your drinking or other substance abuse?
Yes, I do now
Yes, I have in the past
N/A
Have you had legal problems associated with your drinking or other substance abuse?
Yes, I do now
Yes, I have in the past
N/A
Has drinking or other substance abuse affected you financially?
Yes, it does currently
Yes, it has in the past
N/A
Have you ever been seen by a substance abuse counselor or other mental health professional?
Yes, I am presently
Yes, I have in the past
N/A
Has drinking or other substance abuse caused problems in your relationships?
Yes, it does now
Yes, it has in the past
N/A
Has your drinking or other substance abuse affected your work?
Yes, it does now
Yes, it has in the past
N/A
Have you experienced "fuzzy" recall or "blank periods" as a result of your drinking or other substance abuse?
Yes, I do presently
Yes, I have in the past
N/A
Have your behaviors while drinking and/or using other substances resulted in you doing something embarrassing or stupid?
Yes, it has recently
Yes, it has in the past
N/A
Have you been in the hospital or institutionalized on account of your drinking or other substance abuse?
Yes I have recently
Yes, I have in the past
N/A
Have you ever been arrested and held in jail, even if only for a couple of hours?
Yes, I have recently
Yes, I have in the past
N/A
Do you drink or use substances in the morning?
Yes, I have recently
Yes, I have in the past
N/A
Do you drink alone?
Yes, I have recently
Yes, I have in the past
N/A
Do you have arguments while drinking?
Yes, I have recently
Yes, I have in the past
N/A
Have you been in a physical fight while drinking or using other substances?
Yes, I have recently
Yes, I have in the past
N/A
Do you drink or use other substances to escape from worries or other troubles?
Yes, I have recently
Yes, I have in the past
N/A
Do you drink or use other substances to decrease tension?
Yes, I have recently
Yes, I have in the past
N/A
Do you drink or use other substances to reduce anxiety/fear or self-consciousness?
Yes, I have recently
Yes, I have in the past
N/A
Have you hidden alcohol or other substances?
Yes, I have recently
Yes, I have in the past
N/A
Do you want to quit drinking?
Yes
No
N/A
Do you want to quit other substance abuse?
Yes
No
N/A
Do you want to reduce your drinking?
Yes
No
N/A
Do you want to reduce your other substance abuse?
Yes
No
N/A
Have there been periods of time that you drank or used substances daily?
Yes, I have recently
Yes, I have in the past
N/A
Have you ever been diagnosed with.. (Check all that apply.)
Bipolar Disorder
Schizophrenia
Depression
Borderline Personality
Anxiety
Generalized Anxiety Disorder
Panic Attacks
Eating Disorder
Obsessive Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Are you currently working with another counselor or therapist?
Please list all past & current counselors, therapists, psychologists, and psychiatrists you have had. Include any times you have been admitted to a mental health facility. (Include name, organization, location, beginning and end dates, initial reason for seeking help, and any diagnosis received along with medication prescribed.)
What was the outcome of the counseling/therapy? Was it helpful? If not, why?
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Marriage & Family
Name of Father
First Name
Last Name
Is your father living?
Father's Religion
Name of Mother
First Name
Last Name
Is your mother living?
Mother's Religion
Describe your parent's involvement in your life.
Parents were.. (Check all that apply.)
Never Married
Married
Separated
Divorced
Remarried
Your age when parents separated.
Your age when parents divorced.
Were you raised by anyone other than your biological parents?
Please list your siblings from oldest to youngest, including yourself. Mark step-siblings with an asterick (*).
Marital Status (Check All That Apply)
Single
Dating
Engaged
Married
Separated
Divorced
Widowed
Remarried
Living Together & Unmarried
Name of Spouse
First Name
Last Name
Age of Spouse
Religion of Spouse
Highest Level of Education Completed by Spouse
Employer/Occupation of Spouse
Wedding Date & State
Age When Married (You/Spouse)
Length of Dating/Engagement
Length of Marriage
Have you ever been separated?
Yes
No
Date & Length of Separation
Have either of you filed for divorce?
Yes, I have
No, neither have
Yes, my spouse has
Date Filed for Divorce
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is your spouse filling out an application for counseling?
Your Total Number of Marriages
Please list your children. Include the following information: SC = stepchild/no biological relation to you, NM = biological child whose other parent you are not married to; Name, Age, Gender, Living (Y/N), Occupation, Marital Status.
Other pregnancies you fathered or carried (# of miscarriages, # of abortions).
(Men Only) I could have children that I haven't met.
Yes
No
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Final Questions
Please choose any words that indicate your MAIN issues that bring you to counseling.
*
Anger
Anxiety/Fear
Bitterness
Children
Conflict
Communication
Depression
Finances
Grief
Guilt/Shame
In-Laws
Health
Lifestyle
Lying
Self-Injury
Memories
Emotions
Marriage
Sex/Lust
Sleeping
Addictions/Habits
Eating Issues
Fatigue
Abuse/Violence
Major Changes
Moodiness
Impotence
Deception
Spousal Abuse
Homosexuality
A Particular Vice
Please write a quick summary of your main concerns. Indicate how long you have had these concerns.
*
What have you already done about these concerns? What have been the results?
*
Please describe any significant events related to your concerns.
*
What, if anything, do you fear?
*
What would you like us to do? What are your expectations and goals in coming here?
From whom do you normally receive advice for problems? (Check all that apply.)
Friend
Pastor
Neighbor
Relative/Family
Counselor/Therapist
Other
Were you referred here by someone? (Name & Relationship)
Was your involvement in counseling placed on you as a requirement? If yes, please explain.
Is there any other information we should know?
*
Consent to Counsel
Duty to Warn
Facts About Biblical Counseling
RGCC Appointment Policy
Signature
*
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